May 17, 2008

I’ve been meaning to write a post about Strokes and Head Injuries (sometime after the long-delayed Trauma And You, Part IV), and this isn’t going to be it. It’ll just be a few quick notes.

You have two basic causes for strokes. One is an occlusive stroke: A blood clot gets loose and blocks an artery in the brain. This is very similar to a heart attack, where a blood clot gets loose and blocks a coronary artery (or a pulmonary embolism, where a blood clot breaks loose and blocks one of the pulmonary arteries). The other is a hemorrhagic stroke, where a blood vessel bursts, causing bleeding into the brain, your classic apoplexy. This is similar (in some ways) to a ruptured aortic aneurysm.

When you have someone come down with signs and symptoms of stroke (and these vary depending on how big the stroke is and what part of the brain is affected), you have three hours from the time of onset of symptoms to the start of therapy if you’re going to treat it with anything other than time.

What to do: Do not waste time. You don’t have it. Note down the exact time the symptoms started. Call your friends from 9-1-1. You do not need to have all of these signs or symptoms. Any of them should initiate an immediate call to EMS. This is a true medical emergency.

I’m sure you’ve seen those e-mails about How To Tell if Someone Is Having a Stroke. The three tests (arm drift, smile, repeat a phrase). That’s called the Cincinnati Stroke Scale, and while it’s a wonderful tool, and we use it ourselves, it isn’t diagnostic (and lots of things that have stroke-like symptoms, that aren’t strokes, are plenty serious all on their own).

What happens when the nice EMTs take the person away:

1) We give him oxygen, and establish an IV. We ask him (or you) all kinds of questions about his medical history, allergies, medications, and particularly what time it started. The clock is running.

2) Once at the ED, the emergency physician will order a no-contrast CAT scan or MRI, and at the same time run down the checklist for why not to give thrombolytics. This checklist is about three pages long (“Any recent surgeries? Any recent tooth extractions?”) where any “yes” means the thrombolytic path is closed. The first item on the list is “Has it been more than three hours since the first symptoms?” If yes … well. Make the patient comfortable and see how things go.

Now that MRI: The brain scan has to be normal. In the early stages of an occlusive stroke, there are no visible changes. Free blood in the brain shows up as a lighter area, and bleeding in the brain means we don’t want to break up any clots. Dead tissue shows up as a darker area, and if the tissue has already died, well, no point in going on. Or you could see a tumor, and thrombolytics won’t help with that.

3) If the MRI comes back normal, and the patient said “No” to all the questions on the checklist, then comes the big question: “This therapy could kill you. Do you want to go ahead with it?” Being put on thrombolytics is essentially the same as getting an instant case of hemophilia. If you can’t answer the question because you can’t talk (or can’t hear or can’t read), because of the stroke, better hope you have a Living Will that spells out what you want done, or have someone with a Power of Attorney for Healthcare standing by to answer for you.

4) If you say, “Yes” to going forward … the first drops of thrombolytic have to hit your veins inside that three-hour window. That’s why helicopters get involved. To get you to an MRI machine, to get you to a center where they have the guys who’ve done this more than once a year. Then, you have about a 70% chance of getting All Better.

Of course, if you have a hemorrhagic stroke, what you need is a neurosurgeon to tie off the bleeder and relieve pressure in your skull. Different ball game.

Then there are TIAs—Transient Ischemic Attacks. These are so-called “mini-strokes.” The difference between them and a full-bore stroke is that the TIAs spontaneously resolve within twenty-four hours. Don’t ignore them for that reason: They’re a red flag that a major stroke will hit (60% chance) within twelve months.

So what I think is going on with Kennedy: The helicopter was to get him to a good MRI and a major hospital within that three-hour window. The fact that he’s calling people on the phone and talking to them means that he’s (probably) sitting somewhere watching thrombolytics drip into his veins, bored out of his gourd. Chance of recovery? About 70%.

For all of y’all: If you have, or someone around you has, stroke-like symptoms, Don’t Screw Around. Call 9-1-1.

As always, I am not a physician. I can neither diagnose nor prescribe. This post is presented for amusement purposes only, and is not medical advice for your particular situation or condition.

There was a TED talk by a neurosurgeon who had a left-brain stroke and her description of what it was like to try and figure out how to dial a phone when she was fading in and out of coherence— as well as being entirely unable to recognize numbers— is pretty scary. (And, well, amusing, but she's had something like fifteen years to recover her left-brain skills and a certain amount of humor makes the story more interesting.)

I think the lesson from that is to have 911 on speed-dial, something you can pull up with a combo click, because then you'll be able to pull it off even if your language functions start shutting down.

(CNN) -- Sen. Edward Kennedy was hospitalized in Boston, Massachusetts, after suffering an apparent seizure Saturday morning, his family said.

"He is undergoing a battery of tests at Massachusetts General Hospital to determine the cause of the seizure. Sen. Kennedy is resting comfortably, and it is unlikely we will know anything more for the next 48 hours," a statement from his office said.

John @ #3: That depends on the location of the stroke, and which kind it was.

I just lost a patient to a hemorrhagic stroke with brain swelling and fever; with any one of those three signs I might still have saved him, but the combination of all three was deadly. I've been luckier with others.

(All of my stroke cases are hemorrhagic unless otherwise indicated, because these are research animals with brain electrodes.)

The brain is an odd place. A pinpoint lesion in just the right location can lead to devastating problems and, on the other hand, surgeons can scoop out half the brain and you'd never know it.

Individual stroke mortality depends on a lot of different factors, but I've got figures (from around 2001) noting that 15% of all deaths are the result of strokes, and that 50% of stroke patients die within 6 months of insult. Serious stuff indeed.

Oh yeah: when my father was in the hospital - the big hospital next to the university, not the local one - the neurosurgeon described his chances as slim and none. It was, like his first two strokes, a hemorrhagic stroke in the brainstem. (I sometimes describe it as messing up the connection between the CPU and the main bus.)

I live just a couple of blocks away from a Level IV (Basic) Trauma Facility; I'm not sure if they have a heliport for airlifting patients to the Level II (Major) facility ten miles away. I was shocked to discover that my city doesn't have a Level I facility.

Are EMT's allowed to force locked doors open to respond to 911 calls? I routinely keep my doors locked when I'm home alone.

One thing that needs to be noted is that a stroke can hit at any age. My best friend at university died of a stroke at 23.

I'm sorry to hear that. My older sister survived a severe stroke at 19...she had endocarditis, which sent a clot into her brain. She didn't make a full recovery, but she's 53 now with grown-up kids and 3 grand-kids, so she's done very well. All hail the Chicago Rehab Institute, which got her walking and talking again within a year when her regular docs feared that she would never manage either.

Jim, I didn't express myself well. What I meant was, just how dangerous is the treatment? I'd be inclined to risk about anything short of sure death to alleviate the effects of a stroke. Stroke scares me.

John #14, I don't know that answer. I suspect it depends on your general health, the particular situation you find yourself in, the exact therapy being considered (there are several different drugs available, each with their own advantages and drawbacks). If the situation arises, ask the doctor on the scene, consult with your conscience, and roll the dice.

In about another month it will have been five years since my husband woke me up at 3:15 AM - and at first I couldn't understand what he was about but then I realised two things - his speech was VERY slurred, and what he was saying, or trying to say, was, "I think I am having a stroke".

You don't wish this on your worst enemy. I've never woken up so fast in my life, or felt quite as helpless. And I did all the wrong things - he wanted water, and I brought him some, not knowing of the danger that he might aspirate the stuff and get it into his lungs because the swallowing reflex was gone; he wanted up, and I tried to help him get out of bed, which is when we both realised that his right side was utterly dead because his leg collapsed underneath him and he went down like a sack of potatoes.

All this took less than ten minutes. At this point, I grabbed the phone and dialled 911.

We live just up the hill from the local fire station/paramedic first response station. They were at my house in another ten minutes or so. They took one look at him, slapped oxygen on his face, bundled him on a gurney, and screamed off in an ambulance to the hospital ER - where, for a WONDER, there was absolutely nobody requiring more urgent care and my husband was bundled out of the ambulance, admitted, MRI'd, and diagonsed almost instantaneously. It was just after four o'clock that I left the hospital, because they told me to go home because there was nothing else I could do there just then and to come back in teh morning.

We had just moved to a new place. I knew nobody. I knew nothing probative about strokes, not when they struck this close to home.

He was in ICU for about 3 days, then transferred to a general hospital room for another three or four until they stabilised him - but his right side was still dead dead dead and he was eating babypuree mush because his swallowing reflexes were simply not reliable enough for solid food. Then they transferred him to a nursing home facility to get a little stronger before they turfed him to rehab, and oh god, what fresh hell was this, I left him there amongst all the pitiful forgotten old people left there to die and came home and cried for three hours and then both he and I pushed as hard as we could for him to be transferred to the inpatient rehab unit as quickly as possible.

He now walks without a cane, although he still drags the right foot, and his right hand is still lacking a functional opposable thumb - but as I keep telling him, if we need to live without one hand we can adjust as necessary, what I am SUPREMELY grateful for is the fact that his personality didn't change, that he himself remained behind after that massive stroke and didn't become someone else altoghether, which I have heard is not uncommon with stroke victims if the stroke was in a particular area of the brain.

His recovery THIS far is due to the fact that he got treatment well within the Golden Hour - whatever could be done was done and he was lucky to get it as quickly as he did. I'm just sorry I wasted those first few precious moment trying to "help" in my own clumsy untrained way instead of calling the professionals immediately.

What I call his fifth re-birthday is coming up on June 20. I still feel a superstitious frisson of fear going to sleep on the night of June 19th. I'm still haunted by the memory of that night.

A couple years ago, a good friend of a good friend (aged 38 at the time) woke up one morning feeling Not Right At All. He was able to get on webmd.com and look up his symptoms, and realized that he was probably having a stroke. He lived only a couple blocks from the nearest hospital and was still able to move, so he walked to the ER and was able to tell the triage nurse "I'm having a stroke" before he was no longer able to stand up.

They didn't believe that he was having a stroke. They assumed he was a druggie having a bad trip, didn't do anything more than have a nurse check him over in the waiting room, and tried to send him home. He managed to convince another nurse to call his GP, who happened to be in the hospital checking up on another patient and came down to the ER and only then did he get treatment. His left side was affected, and while he could still see, he was no longer able to read.

Considering what happened when he went to the hospital, I call the fact that he made a full recovery a total miracle.

Susan @ 12: How recent do surgeries and/or tooth extractions have to be to make the thrombolytics a problem?

I'd hazard to guess that with the reference to becoming an instant hemophiliac, issues arise with not fully healed cuts, a lack of clotting and these things occurring out of sight (internal bleeding). Maybe there's also a blood thinning element to it all, as well.

Susan @ #12 - my guess is it has to do with areas where your blood vessels are likely recently damaged and not up to snuff, and you'll start bleeding out in those regions. They don't want to create even more problems.

I'm not a medical professional, I just hang out with (and work with) a lot of them, and have a mother with more things medically wrong than you can shake a stick at.

I've worked in inpatient rehab. I have another piece of advice: exercise every day. This will not only decrease your chances of having a stroke, it will speed your recovery if you ever do have one.

Also: emotional lability (mood swings, loosely speaking) and a tendency to tearfulness and depression are very, very common following a stroke. Many stroke patients and their families don't know this, and think it's a character defect/mental illness/brain tumor rather than just another symptom of the stroke that will improve with time.

John @ 14: The risk of treatment is that tPA (Tissue Plasminogen Activator) will cause bleeding somewhere else, including someplace in the brain, and create more damage. There is a "1 in 15" chance that you'll have a fatal bleed with tPA treatment. We don't know the risk factors associated with that, and most doctors are too wary of using tPA even in an ideal setting. As it becomes standardized treatment, more people will get tPA, and we'll get a better understanding of all the associated factors.

Most human strokes are ischemic, so tPA is the drug of choice, except there's the three-hour window, plus your blood pressure needs to be in the right zone, plus your other risk factors need to be in the right place. There are surgical methods to break up a clot in those cases; carotid endarterectomy, balloon angioplasty, and catheter embolectomy are some of the procedures that can be done.

Of course, if you are diagnosed with a hemorrhagic stroke, you'll be going to surgery for repair.

Is one of the questions on that checklist "do you have frequent nosebleeds?" That's been a chronic problem most of my life, and it's why don't use aspirin. Is this something that should be on my medical record? My current MD seems to think it's too trivial to chart. I'm especially concerned because my mother has a history of TIAs and strokes.

Alma, it was good to hear from you. Of course you two sprang to mind immediately upon seeing the subject of this thread. My love with you always.

Jim - who should take an aspirin every day? Everybody, except those on anti-coagulants perhaps? Everybody in a certain high-risk group defined as...? (Aspirin has, as of recently, become my pain-killer of choice, after years mostly relying on ibuprofin. I have no rational reason for this new preference. I'm glad to hear it possibly has a good side-effect.)

If it worries you, it should be on your chart. An emergency doctor then has the info and can decide whether or not it's important.

Evil Rob has a hereditary sensitivity to sulfties. Sometimes it surfaces, sometimes it doesn't. In his case, it seems to be a combination of sulfites and alcohol that is dangerous, and he gets food poisoning, but one of his sisters reacts more strongly and gets classic anaphylaxis.

Sulfites are sometimes used as preservatives in medical prescriptions. So even though I don't have any allergies of these sorts, this is something I have to know...

...because it runs in Evil Rob's family. And the Dude might well inherit it.

You can bet this is going to be one of the first things on his charts, even though he may have no hazard at all. And yes, I made a point of it when filling out the pregnancy paperwork.

In general, nosebleeds are not correlated with stroke, except if you have hypertension, which rarely causes nosebleeds and is a risk factor for stroke. Most nosebleeds are caused by damaged, irritated or dry mucous membranes, some specific drugs, colds/flus/allergies, or a deviated septum. There are some other conditions that can cause rare nosebleeds, though. If you can identify the likely causes, you'll be able to rule out (or rule in) any risk of tPA treatment should you ever need it.

Your mother's history of TIAs and stroke is more important with respect to your risk of getting a TIA or stroke.

Meredith #19: They didn't believe that he was having a stroke. They assumed he was a druggie having a bad trip, didn't do anything more than have a nurse check him over in the waiting room, and tried to send him home.

Sometimes it's hard to get medical professionals to believe you. I had a nurse who was supposed to give me a dose of IV antibiotics get distracted and when she didn't come back, the charge nurse didn't believe me when I said it hadn't been done, because the original nurse filled out the completion paperwork before doing the job. They ran me through humiliating disorientation tests for a while, and only admitted to the error after contacting the nurse, who had gone off shift for the day. It's a heck of a thing when they think you're wrong, have paperwork to back them up, but you know you're right. I was ready to call 911 to rescue me from that damned hidebound hospital.

When putting me on ASA (aspirin) a few years back, my primary commented that she didn't believe the 81mg dose being used commonly did much good. She cited some research (which I can't find now of course) that stated that even a full 325mg tablet would provide sufficient coverage for about 75% of the at-risk population. The street doc I volunteer with also believes in using the regular dose tablets for his cardiac patients.

I now take one 325mg tablet a day, plus use it for my frequent sinus headaches. If you are on, or think you might benefit from being on, an aspirin regimen, discuss the latest research on dosage with your doctor.

Disclaimer: I ain't be no docolator, I only are be a nursey who wants has cheezburger now, so: What Jim said way back up there...

A word on recovery... Get An Occupational Therapist (the past two years have sensitised me, and some interesting conversations were had tonight).

OT is a much misunderstood discipline (even in the field, I was encouraging the Head of OT at Walter Reed to go talk to Rheumatilogy and see about getting referrals; because the sort of patients they get can use, and it's not known there; as I know from seeing, now; that I needed it then).

OT is about being able to things, not about being able to work. It's got a lot of pieces, but stroke victims are prime candidates, and a good OT can be the difference between merely being alive, and living a complete life.

My stepfather (81) had a stroke last year. Happy ending, he got treated quickly, and everything has resolved well. HOWEVER. The initial symptoms appeared in the early afternoon, and my mom realized right away what was probably happening. My stepfather was fully conscious and lucid, but very reluctant to have 911 called.* My mom sweated blood while she was trying to talk him into it. There was no way she could have supported him into the car to get him to the ER herself, and she was well aware of the window of opportunity, but if he flat refused, there was nothing she could do. As far as either of us knows, anyway.

*Why the reluctance? A combination of denial, not wanting to 'bother' anyone...

Echoing Mary Dell @13, bacterial endocarditis is another cause of stroke or TIA, albeit an unusual one. About three years ago, my dad (then aged 80) had been feeling run down and having back pains for a couple of months, and had what looked like a TIA one night. (I wasn't around; it was down to my mother and sister to figure out what happened.) He was feeling increasingly ill and running a low-grade fever, so they called an ambulance; he was in the hospital, waiting to be checked in, and while he was in the toilet he collapsed with what was diagnosed at that time as a stroke.

The clue that it wasn't a stroke was that he was feverish and his blood pressure was on the low side of normal. Over the next 12 hours they figured out that it was severe bacterial endocarditis and a festering infection of his lower vertebrae, that was throwing off bacterial plaques and had occluded one of his cerebral arteries, at which point they got him started on about 10g of intravenous penicillin per day (yes, it was a non-drug-resistant infection in this day and age) and began getting things under control.

(He made a surprisingly complete recovery -- especially in view of his age -- but it was a barrel of No Fun At All for about the first two months. On the other hand, if you're going to have a stroke or a TIA or something like that, the best place to have it is inside one of the largest teaching hospitals in the country; saves on the helicopter and ambulance rides.)

I've been a little freaked out lately about blood clotting as a thing, and now I'm worrying more. My grandfather on my mom's side died of a stroke, and my mother had a deep vein thrombosis while pregnant about twelve years ago. (I think my grandfather's may have been a hemhorragic stroke, on the other hand, but I'm not sure. I do recall it was very sudden.)

So here's the freak-out: I've been having a weird pain in my thigh that comes and goes, located in a spot where it could be related to the saphenous vein(s), and got it initially when I was sitting in the same position for a long time. Of course, being the hypochondriac I am, I got to the hospital right away. It took four visits before they sent me to the right department to get an ultrasound scan, and by then the leg wasn't hurting and the technician didn't find anything. It concerns me that she looked at the central vein (which was fine) but forgot to look at the veins in the area I was worried about, and I'm still not so sure she looked in the right place the second time -- translating English to Mandarin through a translator who doesn't understand medical terminology is a dodgy art at best.

I did find information to the effect that most non-deep-vein clots break up on their own before anybody notices, but I also have a twelve-hour flight to take two weeks from now. I know long flights increase the risk of clots forming (and that doing exercises, taking aspirin, drinking lots of water, etc, is indicated for everyone sensible, and I'm going to do these things with fervent paranoia) but I also can't seem to find anywhere on the whole Internet is whether they increase the risk of a minor clot moving, so I'm not sure what to do on the chance that I have one.

Apologies if I'm coming off as a complete raving loon here. Having enough knowledge to articulate my concerns, but no way of knowing whether my translator is getting them across to the doctor or whether the doctor is understanding them, has put me into a state of intense alert about my health simply because if something dramatic happened I'd be about as able to communicate it as someone who showed up unconscious.

An easy way to remember the Cincinnati Stroke Scale is to think FAST:
FACE - can they smile?
ARMS - can they hold their arms level?
SPEECH - can they repeat a phrase?
TIME - what time did the symptoms start?

Jill Bolte Taylor's story about witnessing her own stroke was fascinating the first time I read an article she wrote about it several years ago, but I had no idea that she was such a good speaker. Here is her TED talk on her stroke from the TED site. Her book "My Stroke of Insight: A Brain Scientist's Personal Journey" is in print (reissued as a hardcover).

Unless Congress takes action before July 1, the "exceptions process" that allowed Medicare patients to appeal the $1810 cap on outpatient physical and speech therapy services will expire.

That $1810 (per year) is for speech therapy and physical therapy combined. Put crudely, what that means is that if you have a stroke and Medicare is your insurance, you can either learn to walk again or you can learn to talk again, but not both.

BTW, what Terry said @ #32. Inpatient rehab, for example, is divided between PT, OT and ST (speech therapy). You'd see OT for all the hand-related stuff (dressing and feeding yourself, opening doors, etc.), ST for speech problems but also for eating and swallowing problems, and PT for all the mobility-related stuff (getting from bed to chair, relearning how to walk, etc.) As of July 1, OT will also lose the exceptions process for its therapy cap.

A.J. Luxton @37
You are not coming off as a raving loon. I am so not a medical professional, BUT, I have a weird, comes and goes, pain in the front center of of right thigh which was finally diagnosed as caused by a pinched nerve in my spine. (It's not sciatica, because it's not the sciatic nerve.) It took some time and the right MRI to figure it out. Many circumstance cause pain, and it's not always easy to find out what's going on, and if something needs to be done, or even can be done. If you're going to take a long flight, precautions are a good idea. Hopefully, once you're someplace where communication is easier, you can find out if there is anything that needs to be treated.

Jim@18: what's your latest reading of info on weight/fat-ratio/BMI? The last I consider very debatable because there's no correction for skeletal proportions (e.g., a broad-shouldered 28 might be as fit as a stringbean 22), and the others report contradictory info on how much they affect the direct parameters of blood pressure and cholesterol. Or does that come under "lifestyle", along with food choices, exercise, ...?

Aspirin is definitely something to discuss with one's GP, as research keeps finding new plusses and minuses; note also that it's easy to find "baby aspirin" (not always called that because of major questions about aspirin for children, but convenient for adults thinking about heart health because it's the same 1/4-dose that St. Joseph's (et al?) used to be).
wrt edward@31: there's a difference between what's recommended for ]cardiac patients[ and what's recommended for more-average people. e.g., my wife was told 1/4-tab-a-day at age ~47; I discussed this at age ~52 with my GP-training-in-cardiology, who said 1/4-tab-every-other-day was "OK". Usual disclaimers, plus this is all informal/anecdotal; \somebody/ ought to be doing a proper analysis of all the studies, if only to work out what needs to be done to get a clearer answer to whether/how-much, but I haven't read anything suggesting that this is happening.

meredith@19: I hope your friend reported that hospital to the state certification board. Emergency rooms are \incredibly/ difficult places to work well in, but there's always a chance that this one could worked better if properly reviewed.

AJ: to make you feel worse, the last PE I dealt with was a nice lady who'd flown from California to Boston, then drove another four hours (as a passenger) up here in a rental car for a wedding--a whole lot of sitting, not much moving. Made the reception more memorable than it should have been, when Auntie X suddenly had chest pain and shortness of breath at the buffet table.

If it helps any, a leg clot that starts moving will probably wind up as a PE, not as a CVA or AMI. (Between your leg and your brain come a whole lot of capillary beds.)

Comparing the two modalities in patients with suspected acute stroke, the investigators found that the sensitivity of MRI for diagnosing acute strokes was 83%, compared with just 26% for CT performed on the same patients.

Another point for regular exercise: it will help you deal with apparently unrelated medical stuff.

I had my gall bladder out a few weeks ago. I think part of why they let me go home from the hospital as soon as they did is that I was able to get out of bed on my own and walk to the bathroom and back within a few hours after the surgery. And that was in significant part because I realized that okay, the abdominal muscles aren't in good shape right now. So, get to an upright position using the bars on the side of the bed, and the biceps and triceps, and from there it's all quads and calf muscles. All of which were in good shape, because I work out regularly using free weights and Nautilus-style weight machines.

(I have the doctor's clearance to go back to the gym, but am not actually up for it yet: at this point a full day's work, in my desk job, is tiring enough that I'm not heading gym-ward at the end of the day.)

Yes, I'd be recovering from the surgery without those muscles, but it would likely be going more slowly, and I was very glad to get home the day after surgery, not be kept there longer to recover with nurses and doctors nearby. No strangers sharing the room and watching stupid daytime television. No being awakened every four hours so they could check vital signs. Et cetera. It's a good hospital, and they did well by me, but I was glad to be home, and glad to leave that hospital bed for the next person who needed it.

One thing people might need to be aware of: a doctor's willingness to administer tPA goes down as the patient's age goes up. That is, while patients in their fifties and sixties might automatically get considered for the clot-buster, patients in their eighties are unlikely to be offered that option. Even if they (or their families) ask for it, they are likely to be told it's suicidal. Again, it all depends on the patient's physical condition, at any age: as several people above have indicated, the better shape you are in when you have the stroke, the better your prospects for recovery will be (in several senses).

Earl Cooley III @ #10: apparently they are -- I woke up a month or two ago to the sound of someone battering down the front door to an apartment down the hall from mine. Turned out to be a police officer forcing the door to let in EMTs to assist one of my elderly neighbors who suffered some sort of medical emergency. (Sadly, the outcome seems to have been poor -- the apartment is empty now.)

I never did answer Earl's question; Tom S. has it right -- we call the cops and they gain access. (Among other things, they're trained to do so, and they can stay behind afterward to secure the scene.)

chip @#39: Here's a nice breakdown (PDF format) of the various methods of body fat analysis. (Scroll down to Table 1 on the second page for a fast summary.) Basically, there's (a) a tradeoff between accuracy and ease/cheapness of use; and (b) the whole issue of WHERE the fat is, which makes a big difference risk-wise, but some methods don't take it into account.

re OT: Lila is right, that hand therapy is what they will try to give you for OT, but it should be more than that (and it's one of the battles Maia's generation of OTs is going to have to decide to fight. I can see OT getting itself narrowcast, and overspecialised).

There is OT for swallowing, walking, bathing, eatig, using hands and arms, getting around your house, and almost any other way in which one can occupy one's time (I could start trying to explain the differences between activities, and occupations, but that's not really relevant; save to say that an OT will help with both).

Vicki's comment at 43, about how she worked around her muscles difficulties is something an OT will work with one to figure out how to do (no, I am not an OT, nor do I play one on television, but I've been made into an advocate of the idea. It's funny how sensitisation works. I can see all sorts of places an OT would be really helpful; and have come to realise we could use a whole lot more of them, because good OT is preventative, as well as restorative).

#33: When my Nana fell and broke her hip, she refused to let my mother call the ambulance. My mother had to call my dad so that he could call the ambulance.

I'm not sure why it is that some people don't want to face the medics even in the face of overwhelming evidence that they're necessary, or why they use the emotional levers to keep someone from helping them. Thankfully, I won't have that problem— my parents have learned from such experiences and are in the "better to pay for the emergency trip than miss something dire" crowd.

AJ:
I had a blood clot last month in my lower leg. I more or less guessed what it was because it felt like a large knot running along the vein with blood pounding in it. The vein itself was swollen - I could see it through the skin - and the leg was somewhat swollen and inflamed in about a 3" diameter circle around it. It was quite agonizing and quite distinctive and showed up one day at work for no apparent reason. It did not feel like a bruise or any other sort of pain, and it really pulsated. I don't know if this is typical of superficial blood clots or not, and IANAD etc.

I didn't go to the doctor until a regularly scheduled appointment a couple of weeks later, where she confirmed my guess and sent me off for an ultrasound to confirm that it was purely superficial. Yes, it was stupid to wait, but I'm not used to having health insurance and always have to get over my depressive mental hurdles with things like this ("Hmm, this might be serious and life-threatening. Does that mean I should see a doctor or avoid one?")

The only treatment she recommended was warm compresses. It did resolve on its own after a total of about three weeks, and I flew last weekend with no difficulties. (Well, no difficulties related to my physical condition. The flights home were a weather/O'Hare disaster.)

When my father had a stroke in 1989, they did an MRI, and found damage from the previous incident in (IIRC) 1973, which we'd been told at the time was a TIA. I don't remember if the CAT scan showed anything.

Susan @ 50: Hmm, this might be serious and life-threatening. Does that mean I should see a doctor or avoid one?

In the US, I haven't got insurance; in China, I haven't either, but healthcare is cheap. Unfortunately that adjective applies to quality as well as price, and there's the translation issue mentioned above. So I always try to get things checked out early here, which has resulted in several false alarms, because the whole emergency health care situation seems like a disaster waiting to happen. On the other hand, back in Portland, I live about a mile (straight shot) from a good hospital, so I at least have the comfort of knowing that should that little random symptom turn out to be something suddenly dreadful I can expect equally sudden care...

It's good to know that being potentially clot-prone does not mean flying will automatically cause disastrous effects. Thanks.

I've heard a lot of different descriptions of what a blood clot might feel like, and that they can also be asymptomatic, which hasn't helped my paranoia any, but non-bruisy is also a useful descriptor towards calming me down -- the area of my leg that I'm suspicious about feels bruisy, but doesn't look like much of anything except a little swollen in no particular pattern.

I'm glad I didn't know of this list ten years ago; that was when I had my first migraine, and I was nervous enough without knowing how closely the symptoms matched. My thoughts were, "Is it a seizure or a stroke?" but I had nothing but fiction to draw on, so any worry went away. So did the headache, after a few hours of sleep, and once my parents got me to a doctor they said I was fine.

Thanks for posting this, even if it would have sent my fourteen-year-old self into a panic. It's good to know.

PJ @ 51: A CT scan is not likely to show scars or lesions in the brain, especially not in comparison to MRI. CT is an X-ray device, and X-rays are not a good means of assessing a very soft tissue like brain. MRI is much more useful, as it distinguishes tissues based on water (forex), and you can see white matter versus grey matter.

For a site that shows both MRI and CT images in slice-matched patients, take a look at the Whole Brain Atlas

My uncle had an occlusive stroke in the late 1980s, when he was 35 years old. He realized while sitting at his desk one day that he'd lost feeling in one of his legs, and the numbness was spreading. He called 911, and was able to crawl to the door to unlock it; by the time they arrived, he could no longer move or speak.

He was active, a non-smoker, and had no risk factors we knew of. He was just really unlucky.

The good luck started when he got to the hospital. The neurologist had just the previous month been to a medical conference, where he had gone to a presentation on a promising new treatment for stroke, tPA. The results were preliminary but very encouraging, aside from the fact that some of the patients died instead of recovering. The neurologist was willing to give it a try; my uncle was no longer able to consent to treatment, but they were able to reach his wife, who did; and they started treatment within the three-hour window.

The recovery was not instantaneous, but it was truly remarkable for the time, when the standard care was just to wait and hope for the best. I think he did take the fall semester off (he's a university professor) but he was teaching again by January. He felt like his speech was still a little slurred, so he arranged to have his classes videotaped and said he came out of it a better teacher.

One of the scientists I work with happened across a neat finding with regards to stroke... Apparently once the clot is dealt with and blood flows back into that area of the brain, the white blood cells called neutrophils, the shapeshifting motile gooey ones, look at all the cells that have been starved for food and say, "Eh, looks wrong, destroy it!"... So you lose a lot of brain to your own white blood cells. But W.H. Chou found that neutrophils without Protein Kinase C Delta didn't move/stick/work as well, so the same amount of stroke caused much less brain damage in PKCd knockout mice because their neutrophils couldn't wipe out as many cells which apparently recovered fine.

I'm not sure if that finding is being medicalized; I'm not sure if there are blockers of PKCd. But it is interesting that all the time new stuff is being learned... I mean, they're an addiction lab studying PKCd for its effect on choices to drink, and yet random other useful info appears.

I'm very lucky. I was already in the hospital when a medication the doctor prescribed caused my blood pressure to drop too fast too low and caused a stroke. The kidney doctors had been sure I was going to die from the renal failure, so they were *really* sure I was going to die from the stroke and didn't have a neurologist see me.

I don't remember the stroke itself, the last thing I remember is the taste of the nifedipine under my tongue. The next thing I remember is waking up in a little room with a lot of tubes in me and trying to remember the name of the box on the wall with pictures. The nurses in the ICU noticed the change and came in -- I'd been there six weeks. Turned out I could talk (once the tube was out) but I didn't have nouns. They came back in about six weeks and then I had to learn to walk (PT) and read (myself) and take care of myself (OT) again.

I'm partially paralyzed on the left (not as strong and if I use the arm or leg too much or for something too heavy, it will stop working until the morning, and my left leg drags when I get tired), have balance control problems, and dysphasia. I can't walk very far, so end up not going places unless lovely people like Charlie and Feorag are willing to push me in a wheelchair. Not bad considering I should have died several times over.

But something else to watch for with someone who has had a stroke or similar problem is that it may become overwhelming. I tried to kill myself in the hospital once I realized what had happened. It was weird -- I picked a time where usually nobody came in for three hours, but my resident decided to stop by, and took the bag off my head. I have ongoing depression because a lot of my brain is dead (lots of it rewired, too) but these days when it surfaces, I talk to the doctor about new antidepressants.

These days I get EEGs more often than MRIs (and thank Ghu the electrode gunk now comes right out of your hair) and I started having brain seizures (just little lightning storms in the brain) a few years ago. The neurologist told me it's not unusual in someone who survived that bad a stroke and managed to live this long (21 years). I take phenobarbital for it.

I have a DNR for stroke. Studies show that people who have subsequent strokes rarely live to leave the hospital and I don't want to end up like Terri Schiavo.

I carry a hot pink paper in my wallet with who I am, how to contact my doctor, my insurance, what's wrong with me, and my meds. The same pink papers are in my van visor, the back of the front door, the front of the fridge, with my meds, in the drawer next to my recliner. (Jim, the local medics have never heard of Vial of Life.)

Lauren #63: That was cool! Though the whole broad message (so far, lots of plausible-sounding ideas don't do any noticeable good to avoid having a big chunk of your brain die off when the blood starts flowing again--pretty much what anyone knows how to do now is cool you down) was a bit on the depressing side. And I'm always amazed by the incredible intricacy of the reactions and mechanisms going on, which leads to some insanely complicated description of a process being prefaced with "This, of course, is an almost criminal oversimplification of the real, much messier, process." One thing evolution doesn't select for is ease of description!

They found that normal cells react to a fast by going dormant, while cancer cells don't change, and continue growing. Because they're not absorbing as much from their environment, the fasting normal cells aren't as affected by the chemo, all other things being equal. In the study, the mice that fasted had far less damage than non-fasting mice after chemo.

"Fasting for two days protects healthy cells against chemotherapy... [normal] starved cells go into a maintenance mode characterized by extreme resistance to stresses. In essence the cells are waiting out the lean period, much like hibernating animals. Tumors by definition disobey orders to stop growing because the same genetic pathways are stuck in an “on” mode."

I remember reading earlier this year about a new method being studied to treat glioma:
Clinical trials will start later this year on gene therapy for glioblastoma multiforme (GBM). But of course that'll be just the first stage of a long process to test it.

The technique seems to be a potentially giant improvement in treatment, because it simultaneously attacks the cancer cells and trains immune system cells to recognize the cancer cells. (In mice, the technique also helped restore brain function such as regaining lost control over movement)

Traditional treatments don't work well on GBM, because the blood brain barrier makes chemotherapy less effective, and these cancer cells move around, making radiation less effective.

In the mouse study, viruses (empty) were used to deliver two proteins to the brain. One protein killed cancer cells, and the other protein caused the immune system to recognize the cancer cells as foreign. The combination had much better results than the tumor-killer alone.

I've had three strokes. One was so small I didn't notice it happening (though the MRI shows evidence of its passing); the other two were major enough that I felt them, all right! But I didn't know what they were -- and they were so different it never occurred to me they were the same thing. (One manifested as temporary speech loss; the other, loss of vision in one eye, which I thought was a detached retina.)

It's better to schlep to the hospital & find out it's nothing than to presume it's nothing and find out otherwise. Seriously.

This is very nearly how it went down with my father. A slow loss of hearing that was only noticed in hindsight. Then the seizure, which in his case was small, localized, and motor. Then a massive stroke that took most of his words for six months.

He was a trial subject for the combined radiation/chemotherapy protocol that is standard now. When he was projected to have only two months, he ended up with a year and a half to get his affairs in order and say goodbye. That glioblastoma multiforme that is mentioned in that Daily Kos link... that one does not mess around. It was like Alzheimer's in fast forward.

There's really no predicting this one, but a friend of my father who had the same pattern of hearing loss badgered his doctor into an MRI and actually survived his brain tumor. I think that's luck more than anything else.

A neighbor, twenty years back, had vision problems. He went to his eye doctor, who sent him to a specialist. It was a brain tumor. He survived the treatment - it was successful - but died of a heart attack a year or so later.

PJ #79: I seem to recall reading that this phenomenon is one reason why most medical advances don't have a big effect on life expectancy. When you treat diseases that mostly hit people in their 70s, you just can't have all that large an effect on their lifespan, because something was likley to get them by the time they hit their mid 80s. By contrast, vaccinating against childhood diseases and getting working sewers and water treatment has a huge impact, because a lot of the lives saved were young kids who otherwise could life to their mid-80s.

I'm having a whole lot of freakout about this, which I think is because of the similarities to how a friend died last year, though his was liver cancer. (I had another friend die of a brain cancer, but that was further back.)

I had a friend die of glioblastoma a few years ago. He was a machinist, and the cancer was the same that had hit in a cluster among Pratt & Whitney machinists locally, so we thought that might have had something to do with it.

It wasn't a pretty way to go. Multiple surgeries to very little effect, and motor and cognitive functions dropping off in big chunks. At one point he was still able to process movies but couldn't read text any more -- which is part of my notion of hell.

I grew up in Massachusetts. Ted Kennedy's been Senator there my entire life.

Medical College of Georgia researchers are about to start a phase 1 clinical trial (60 patients total) on minocycline as a stroke treatment. It's an older IV antibiotic (currently used topically for acne) that appears to block apoptosis, inhibit microglial cells (the white blood cells that can damage neurons after a stroke) and protect blood-vessel membranes (so it might also be useful in hemorrhagic strokes).

They already know it's safe in humans and that it crosses the blood-brain barrier.

Because I'm curious about its history...
Seems like it started being used in the 50's for acne, it and other tetracyclines were noted to have anti-inflammatory properties by the 80's (although w/ rare autoimmune side effects).

By the early 90's it was being studied for rheumatoid arthritis (although a quick glance at articles suggests they didn't know why it worked).

Between 1998-2001 various researchers found why it was neuroprotective (it worked against damaging NMDA and microglial activity) and started researching it as a stroke treatment. Here's a 1999 Stanford study on rats that found it reduced inflammation after stroke, if given within a 4 hour window. It also seemed to help in rat models of diseases like MS. But reviews of studies found "variable and even contradictory effects" on how it actually worked against neurodegeneration.

As in, approx 1 in 10,000 get drug-induced lupus from it. I found that one out the hard way. (I had mono simultaneously and was sleeping 16-17 hours a day for several months. I refer to 1999 as "the year I was asleep.")

When I got mono in college, 2/3rds of the way through a quarter, I took incompletes in almost all my classes. The 20 hours of sleep per day only lasted a week, though*.

I've read that other drugs like statins and TNF (tumor necrosis factor) inhibitors also can cause that type of lupus. I wonder if there are any common factors in the drugs causing it?**

--------------------
* and the other 4 hours I spent eating, because I could only eat baby food, and that very, very slowly. All zero-fat foods, too, by the rules of mono. And when I tried to talk, I sounded exactly like Julia Child.

**The latter is also anti-inflammatory, but statins just lower cholesterol.

Mary Aileen, Katherine: Getting mono as a teen (or tween) generally results in about 1-2 weeks of heavy sleeping. As you get older, it gets more difficult to deal with mono. I was 31 when I had it (although I'd probably caught it when I was 29 or so), and I spent 6 weeks in bed following my little hospital stay for severe dehydration.

As for DILE, there's been no common denominator -- some are anti-inflammatories, but others are not. The most cases of DILE have been associated with three drugs (procainamide, hydralazine, and quinidine); there's another 35 drugs that have rarely been reported as linked. It would be nice to know why these drugs and not others, as that could potentially lead to reversal of ILE.

Getting mono as a teen (or tween) generally results in about 1-2 weeks of heavy sleeping.

I was seriously out of it for a little under two weeks, though I had to take things easy for a month or so after.

The way I found out I had mono was, I went to class the first day of the spring semester of my freshman year, and promptly fell asleep. Then I went off to the next classroom, threw up in the trashcan (fortunately no one else had arrived yet), and decided it was time to go to Health Services. They thought I had strep--one of the first symptoms of mono is an epic sore throat--but no...

I ended up not taking German, because missing the first two weeks of a language class is pretty much the kiss of death, but made it through all my other classes that semester.

#39 - Hi CHip - sorry for the delayed response. One of my favorite medical sources is the Mayo Clinic, as they seem to agree with my own primary MD in most cases, and I think she walks on water.

As far as your wife's dosage: Currently, the Mayo information does not describe significant success with daily aspirin therapy in preventing first heart attacks for women under 65... WebMD still seems to favour the 81mg dosage. The primary reason for the lower vs. higher dosage controversy seems more related to the trade-off between the benefits of aspirin vs. the side effects of the therapy, rather than just the benefits of higher vs. lower dosages.

Some of the biggest risks of daily aspirin therapy are bleeding and stomach problems (including ulcers). Even though the docs might think it's "ok" for the low-dose regimen, a look at risk/benefit balance is always a good idea. My opinion (which is ONLY just that) is that the highest tolerated dose should be used to maximize the benefits. For my money, a lower risk of dying by heart attack or stroke is worth a potential increase in the risk of an ulcer or artificial hemophilia.

For men and women, the dosage varies depending on how many risk factors. My primary MD put me on a full aspirin a day at age 37. There is a strong cardiac history in my family. I am obese, diabetic, and had an enlarged heart back in the '90s. That's a lot of risk, so there was no doubt in Doc's mind that I needed a full aspirin. She also suggests that I make more use of regular aspirin in regular pain relief, as it does not affect my stomach. As I have frequent sinus headaches, I often take two aspirin along with decongestants before going to sleep. She approves of this.

For anyone with a personal cardiac history, aspirin is merely the beginning of a combined regimen of medication, diet and exercize. Most of the data I've seen agrees that SOME dosage of aspirin is appropriate for helping to prevent a second heart attack. My own (admittedly limited) research in talking to cardiologists and internalists seems to point to the higher dosages.

Disclaimer: I'm a nurse and not a doctor. All free advice from non-MDs is potentially worth only what you paid for it. See your own doctor before starting or modifying an aspirin regimen. Close cover before striking. Offer good while supplies last, and void where prohibited or taxed.

Lila (90): That's a nasty combination, too. I was sleeping every chance I got from January to October (hence "the year I was asleep"), but part of that was because one of the allergy medicines I started that spring made me groggy. (I didn't figure that out until the next spring; at the time, I thought it was just part of the mono + lupus experience.)

Carrie S. @ #93, she had so much trouble swallowing that she nearly had to be hospitalized for dehydration. Luckily she managed to suck on a few popsicles, and that held her until the antibiotics started knocking out the strep.

My biology teacher in high school told me a story (I was his summer school TA) about teaching a phsyiology class, on of the students asked him what the results were on the blood typing experiment because it wasn't making sense.

Ginger, let's just say I feel slightly better now I know that the plant I think I was thinking of is being used as a control rather than being the epicenter. (Anything more is TMI about someone other than me.)

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